791:   A coronavirus Mystery Riddle: Why Some Places fare Better

Adapted from an article in New York Times

Corona Mysteries

Variable Death Rates: World: 7%; Europe: 9.7%; North America: 5.82%, South America: 5.1%; Africa: 3.91%; Asia 3.51%; India: 3.27%; Oceania 1.36%

Variable Deaths per Million Population:  Spain: 540, USA: 207, Europe: 131; North America: 43, World: 31.8, India: 1; India, Pakistan, Nepal, Sri Lanka, Bangladesh: 0.7.

Asia: 5.7 (11 countries average 0.44; 10 countries average 1.6; 11 countries average 3.9; 3 countries average 9.6 and 3 countries (Israel, turkey, Iran) average 41.3)

The coronavirus has affected 112 countries, but its impact has been uneven. Metropolises including New York, Paris and London have been devastated, while teeming cities like Bangkok, Baghdad, New Delhi and Lagos have largely been spared thus far.

New York: 323,883 cases; 24648 deaths; 16509 cases per million population; 1256 deaths per million population

London: More than 24700 cases and 5156 deaths; ONS analysis shows there were 55 deaths for every 100,000 people in the poorest parts of England, compared with 25 in the wealthiest areas.

Thailand: 2969 total cases with 54 deaths

Iraq:  2296 cases with 54 deaths

Nepal: 75 cases with no death

Why the virus has overwhelmed some places and left others relatively untouched remains a puzzle. Each possible explanation seems to come with caveats and counterevidence.

If older people are highly vulnerable, for instance, Japan, with its aging population, should have been devastated. But it has 14,877 cases with only 487 deaths.

Is it genetics? Saudi Arabia is studying genetic differences and Brazil is looking into the relationship between genetics and COVID-19 complications.

Experts are also investigating if common hypertension medications might worsen the disease severity and whether BCG or Leprosy vaccine (Mycobacterium W), not vaccinated with H1N1 flu vaccine, current Polio vaccine might do the opposite.

Many developing countries with hot climates and young populations have been able to escape the worst but countries like Peru (45928 cases 1286 deaths), Indonesia (11,192 cases and 845 deaths) and Brazil (101,147 cases and 7025 deaths) have growing epidemics. Maybe the virus just hasn’t gotten to some countries yet. Russia (134,687 cases with 1280 deaths) and Turkey (126,045 cases and 3397 deaths) appeared fine until recently, but suddenly, they are not.

The Spanish flu that broke out in the United States in 1918 seemed to wane during the summer but came back with a more fatal strain in the fall, followed by a third wave in the following year. It subsequently reached far-flung places like islands in Alaska and the South Pacific and infected one-third of the world’s population.

Low testing may be the reason for underestimation of virus’ progress, and deaths. But still, mass burials or hospitals turning away thousands of sick people would be hard to miss, and a number of places are just not seeing them.

Possible answers: Virus, Demographics, Culture, Environment and the Speed of Government Responses.

Virus

1. SARS 2 virus is different from SARS 1 virus, as its infectivity starts much earlier.
2. It mutates slowly than H1N1 virus.
3. Over ten strains of the virus are circulating in the atmosphere that may have different lethality.
4. Phylogenetic analysis of 30 publicly available SARS-CoV-2 samples revealed that SARS-CoV-2 likely emerged in the human population in mid-November 2019.
5. There are different clades of SARS-CoV-2 developing as COVID-19 spread globally. Different clades emerge as viruses evolve. This is completely normal and it does not mean that there are new strains of SARS-CoV- 2 that are more pathogenic than others in circulation right now.
6. Contact time: Significant exposure to Covid-19: face-to-face contact within 6 feet with a patient with symptomatic COVID-19 maintained for at least a few minutes (some say more than 10 minutes or even 30 minutes). The likelihood of contracting COVID-19 from a passing interaction in a public space is minimal.

Demographics

Aging and the power of youth

If we consider that the aging population is the most vulnerable, then Japan should be at the top of the list. But that is not the care.

Many countries that have been able to escape mass epidemics have relatively younger populations. Young people have higher odds of contracting mild or asymptomatic illness that are less transmissible to others. And they are less likely to have high risk comorbid diseases.

Africa has 45380 cases as on today, which reflects only a tiny fraction of its 1.3 billion people. Africa is the world’s youngest continent, with more than 60% of its population under age 25.

But in Thailand and Najaf, Iraq the 20-to-29 years age group has had the highest rate of infection; however, they often showed few symptoms.  Contrary to this, the national median age in Italy (one of the worst hit countries) is over 45. The average age of those who died of COVID-19 there was around 80.

Younger people usually have stronger immune systems, which can result in milder symptoms.

Singapore and Saudi Arabia have seen most of the infections among foreign migrant workers, many of them living in cramped dormitories. Several of those workers; however, are young and fit, and have not required hospitalization.

Along with youth, relative good health can weaken the impact of the virus among those who are infected; however, certain pre-existing conditions, such as hypertension, diabetes and obesity, can worsen the severity.

Japan, with the world’s oldest average population, has reported only 487 deaths; however, the number of cases there has risen with increased testing.

The Guayas region of Ecuador, the epicenter of an outbreak that may have claimed up to 7,000 lives, is one of the youngest in the country, with only 11% of its inhabitants over 60 years of age.

Also, some young people who are not showing symptoms are also highly contagious; the reasons for the same are not well understood.

In an HCFI study in India, density of the population was found to be inversely proportional to the number of COVID cases. In states with average population density of 1185/sq km, the average number of cases was 2048.

And in states with population density of 909/sq km, the number of cases was 34.6. In these, when Chandigarh and Pondicherry (high population density with strict discipline) were taken out, the average density of other states was 217/sq km with average number of cases only 35.

Cultural Distance

Cultural factors, such as social distancing (physical distancing with intact emotional distancing) may provide some countries with more protection.

In Thailand and India, where virus numbers are relatively low, people greet each other at a distance with namaste. In Japan and South Korea, people bow, and long before the coronavirus arrived, they used to wear face masks when feeling unwell. But in Iraq and the Persian Gulf countries, men often embrace or shake hands, yet most are not getting sick.

In developing world, the custom of caring for the elderly at home leads to fewer nursing homes, which have seen tragic outbreaks in the West.

National distancing is also beneficial. Countries that are relatively isolated have obtained health benefits from their seclusion.

Far-flung nations, such as those in the South Pacific and parts of sub-Saharan Africa, have not been as overwhelmed with visitors bringing the virus with them. In Africa, limited travel from abroad is perhaps the main reason for the continent’s relatively low infection rate.

Additionally, countries that are less accessible due to political reasons, such as Venezuela, or because of conflict, like Syria and Libya, have also been shielded by the lack of travelers, as have countries like Lebanon and Iraq, which have endured widespread protests in recent months.

The lack of public transportation in developing countries may have also limited the spread of the virus there.

Heat and Light

The geography of the outbreak, which was seen to spread rapidly during the winter in countries in the temperate zone, like Italy and the United States, and was virtually unseen in warmer countries such as Chad or Guyana, seemed to indicate that the virus did not bear heat well. Other coronaviruses, such as ones that cause the common cold, are less contagious in warmer, moist climates.

But some of the worst outbreaks in the developing world have been in places like the Amazonas region of Brazil, a tropical place.

The virus causing COVID-19 seems to be so contagious that it appears to mitigate any beneficial effect of heat and humidity. But other aspects of warm climates, such as people spending more time outside, could help.

People living indoors within enclosed environments may promote virus recirculation, thus heightening the likelihood of contracting the disease.

The ultraviolet rays of sunlight inhibit this coronavirus. As a result, surfaces in sunny places may be less likely to remain contaminated.

Early and Strict Lockdowns

Countries that introduced lockdown measures early, like India, Vietnam and Greece, have been able to avoid out-of-control contagions. This substantiates the power of strict social distancing and quarantines to contain the virus.

In Africa, countries with harsh experience with HIV, drug-resistant tuberculosis and Ebola, reacted quickly.

Airport staff from Sierra Leone to Uganda started taking temperatures (since found to be a less effective measure) and contact details and wearing masks long before their counterparts in the United States and Europe resorted to such precautions.

Senegal and Rwanda closed their borders and announced curfews while there were still very few cases. They also began contact tracing early.

Sierra Leone reused the disease-tracking protocols that had been established at the time of the Ebola outbreak in 2014, in which nearly 4,000 people died there. The government went on to set up emergency operations centers in every district and recruited 14,000 community health workers, 1,500 of whom are being trained as contact tracers, even though Sierra Leone has only about 155 confirmed cases.

Uganda had also suffered during the Ebola contagion. It quickly quarantined travelers from Dubai after the first case of coronavirus arrived from there. About 800 others were tracked down who had traveled from Dubai in previous weeks.

The Ugandan health authorities are also testing some 1,000 truck drivers a day. Many of those who test positive have come from Tanzania and Kenya, countries that are not monitoring as aggressively, thus raising concern that the virus can penetrate porous borders.

Lockdowns, with bans on religious conclaves and spectator sporting events, definitely work.

Over a month after closing national borders, schools and most businesses, countries from Thailand to Jordan have seen new infections decline.

In the Middle East, the widespread closing of mosques, shrines and churches happened relatively early and probably helped curb the spread in many countries.

Iran was an exception. It did not close some of its largest shrines until March 18, a full month after it noted its first case in the pilgrimage city of Qum. The epidemic spread quickly from there, killing thousands in the country and spreading across borders as pilgrims returned home.

While lockdowns are highly effective, in countries that lack a strong social safety net and those where most people work in the informal economy, orders closing businesses and asking people to stay where they are will be difficult to maintain for long. When people are forced to choose between social distancing and feeding their families, they would choose the latter.

Countries where authorities reacted late and with erratic enforcement of lockdowns appear to have been spared. Cambodia and Laos both had brief strings of the infections when few social distancing measures were in place but neither has recorded a new case in close to three weeks.

Lebanon, whose Muslim and Christian citizens often go on pilgrimages, respectively to Iran and Italy should have reported high numbers of infections. But that is not so.

LUCK

The answer is likely to be some combination of the above factors combined with sheer luck.

Also, countries with the same culture and climate could have vastly different outcomes if an infected person attends a crowded social occasion, turning it into a super-spreader event. Such a thing happened when a passenger went on to infect 634 people on the Diamond Princess cruise ship off the coast of Japan, after an infected guest attended a funeral in Albany, Ga., and when a 61-year-old woman went to church in Daegu, South Korea, spreading the disease to hundreds of congregants and then to thousands of other Koreans.

Since an infected person may not develop symptoms for a week or more, if at all, the disease spreads under the radar, exponentially and seemingly at random. If the woman in Daegu had stayed home that Sunday in February, the outbreak in South Korea might have been less than half of what it is now.

Thailand reported the first confirmed case outside of China in mid-January, from a traveler from Wuhan. In those critical times, Thailand continued have an influx of Chinese visitors. For some reason, these tourists did not spark exponential local transmission.

Also had India closed the International borders or started screening the International visitors, when they detected the first case in Kerala on 30^th January, the situation would have been different.

On the contrary, the Jamatis were responsible for number of cases in Malaysia, Pakistan and India.

And when countries do all the wrong things and still end up seemingly not as affected by the virus as one would expect, we have no answer. The classical case of celebrity Kanika Kapoor in India who attended the party of hundreds and did not cross infect a single one will remain a mystery.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA